FORMAT FOR DECLARING INCOME : AFFIDAVIT

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Paulina Parsons
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1 Annexure-II FORMAT FOR DECLARING INCOME : AFFIDAVIT Declaration of income of Parent /Guardian for the year (ending on 31st March 20.) for the purpose of Scholarships/Free-ship. I (Mother s name) daughter of Shri/ Smt......Presently residing at... and I (Father s name) son of....presently Residing at Solemnly affirm and say as follows 1. That our son /daughter / dependent Shri / Smt/ Kumari.has been Studying in (semester) (Course) in ATDC. 2. That our annual family income in the preceding year ending 31st March 20. is Rs...as per details furnished in the schedule (prescribed as FORMAT C). Under the name written. We also affirm that particulars of Properties held by us are shown in the Schedule. We make myself personally responsible for the accuracy of the facts and figures furnished. 3. That we further undertake that in the event of the particulars given in this declaration being found false. We shall refund to the ATDC DOUBLE the amount of the Scholarship/ Free-ships paid to my ward and the ATDC s decision whether the declaration of particulars is false shall be final and binding on us also render my self-liable for prosecution under the prevailing laws. ( in Full).. Signature of the mother and father of the student To be signed in the presence of Notary Public or a Magistrate/1 st Class Magistrate Executive/Revenue Officer/who would also affix his signature and seal.

2 SCHEDULE TO BE ATTACHED WITH INCOME AFFIDAVIT 1. Details of Agricultural Land Extent of Land held And Income (i)area (in Acres) (a) Independently as owner (b) Jointly as owner (c ) Independently as tenant (ii) Village (iii) Tehsil (iv) Type of Land (v) Source of Irrigation (vi) Crops (vii)survey No (viii) Land Revenue Assessment (ix) Annual Income II. Property held and income (House, Shops, Building, House sites, Plot etc.) Part A (a) House no : (b) Village/ Road :.. (c) Village/ Town / City :.. (d) Area of site :... (e) Rent Derived if any : (f) House tax : (g) Sanitary cess or other: (h) Net Annual Income :

3 Part B Whether the whole or part of land /Building owned has given out to tenants. If yes particulars :. Part C: Income from Shops (if any) a) Address of shop b) Nature of trade... c) License No d) Sales Tax. e) Income Tax Paid. f) Annual Income III. Annual Income. By Parents / Unmarried Brothers and Sisters for. (Year) S.NO Information Required Father Mother Unmarried Brothers/Sisters 1 of the Employer / Self Employed /Own Business 2 Office Unit in which Working / Owned and Designation 3 Office Address with Telephone nos 4 (a)annual Gross pay (Basic Pay +Dearness Allowance + House Rent Allowance+ Traveling Allowance + Bonus +Incentives+ Any other Allowance) +pension without Deduction of Income Tax (Certificate from the employer / Income Tax authority / Revenue Authority may be attached (b) Income from any business/self

4 Employment (attach Balance Sheet. Profit & Loss Statement, ITR and Turnover details) 5. Other benefits like house rent allowance, free house and other perquisites 6. Other source of Income (i) Income from subsidiary industries Part time occupation (ii) Amounts drawn as wages (iii) Any other income N.B (1) Total income of the family should include income of Father, Mother/ Guardian. If any Income for the purpose of Means Test is defined as under (a) In the case income from sources liable to income tax. Income computed after deduction able items) for the purpose of assessment of income tax as per Income Tax rules for the year. (b) In the case of income not liable tax, such as income from Agriculture, etc. the net income that is after deduction expenditure incurred for earning that income.

5 IV Details of all bank accounts of both Parent/ Guardian (as in the bank of the bank Bank branch State District Pin Branch Code Number Bank Account Number Type of Bank Account MICR code of the Bank (Saving/ Current) V Details of PAN CARD PAN CARD No. Mother Father and Signature of Student and Signature of both Parent/ Guardian of the Student

Name of Examination Year and month in which. Examination was held. Serial No. in Merit list. 1. The holder of this card, Shri/Smti/Kumari

Name of Examination Year and month in which. Examination was held. Serial No. in Merit list. 1. The holder of this card, Shri/Smti/Kumari D:\Higher~1\HighL.pm5 page No. 27 No.... ANNEXURE - II LAST DATE OF SUBMISSION OF FORMS 10-8-2012 ENTITLEMENT CARD GOVERNMENT OF INDIA MINISTRY OF HUMAN RESOURCE DEVELOPMENT DEPARTMENT OF HIGHER EDUCATION